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t <br /> Mfr , <br /> sr4-r4 <br /> } < <br /> EE WORKSHEET <br /> DBA r � ' <br /> ADDRESS .S'• 40Y go <br /> Operating .Permi't Application/Annual Inspection Fed <br /> ti <br /> e. Existing Facility and lst Tank @ $150. ► <br /> b. Additional Tanks (# _ Additional Tanks x $50} 't7 f' <br /> A� <br /> 2. r, State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit) . <br /> lace <br /> 3. *Temporary Closure (per tank) Underground Storage Tank* in which <br /> storage has ceased but where the owner/operator proposes to <br /> re-case tank within years. <br /> (# Temporary closures x $80) <br /> 4. *Permanent Closure (per tank) Underc oijnd :ae Tank in which <br /> storage has ceased and where the owns ;:,° : . rias no intent $. <br /> of re-using tank within next 2 years, , <br /> (# Permanent Closures x $90) x <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet g <br /> with your check and the completed application. , .. ', <br /> ; . <br /> ` 4q <br /> n <br /> ° <br /> 5 <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks ° <br /> t r <br /> (1 regular, k unleaded, 1 supreme, 1 waste oil ) F , <br /> la. Existing Facility & lst Tank $150 ` <br /> b. 3 Additional Tanks x $50 ) ' <br /> '> <br /> 2. State Surcharge, 4 Tanks x $56 <br /> 7 g <br /> Total Number of Tanks 4 Total Fee Due $52F 6 I l � <br /> EB 2 � 19�,, g <br /> 3 . <br /> ENVIROMEiVTaL HEALTH <br /> PERMIT//SERVICES, <br /> *Both closures will be conditioned. Contact a Health District Representatives <br /> 12/85 # y <br />